• Service Type*

  • Service Type Requested

  • Province*

  • City*

  • Claimant

  • Date of Birth*
     - -
  • Fluent in English*
  • Western Medical Assessments will arrange for an interpreter at Client's cost.
  • Note: Specialists do NOT want a family member or friend to do the interpretation unless formal translation is not technically possible. 
  • Sex*
  • Return to Work Issues*
  • Retired*
  • Date of Loss*
     - -

  • Client

    For the purposes of this Form, the Client is the company requesting the service from Western Medical Assessments.

  • Claimant's Lawyer

  • Represented ?

  • Injuries / Complaints

  • Is there an absolute deadline for the report?
  • If Yes, select date
     - -

  • Terms and Conditions

  • 1) A file opening fee may be charged to Client, to include but not limited to Medical Director’s fee; admin and/or clerical time; long distance and other disbursements.

    2) Payment for services rendered is due upon receipt of invoice, net 30 days.  Payments are to be addressed to Western Medical Assessments,  17204 106A Avenue, Edmonton, Alberta, T5S 1E6.

    3) Any late cancellation (date will be stipulated in our letter with Appointment details) or no-show fee is the Client's responsibility to cover, terms as in number 2) above.

  • IMPORTANT Notes to Client

  • Once Western Medical Assessments has reviewed the Request and information, should the case be discussed with the Client prior to making arrangements with an appropriate specialist?

  • Discuss*

  • How should the Appointment be scheduled and confirmed? Please select from the following:

  • Directly with Claimant?*
  • Through Client, who will then deal with Claimant?*
  • With Claimant’s Lawyer, who will then deal with Claimant?*
  • When did you inform the Claimant that the Assessment is imminent?
     - -
  • In order to provide you with our best service, please.
    • When sending in available medical and other related information, print and attach the confirmation Request form you will receive by email;
    • Advise the Claimant that you’re making arrangements for an Assessment through Western Medical Assessments;
    • If the Claimant has a Lawyer, please ensure that he/she agrees.
  • Should be Empty: